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introduction

Venous ulcers (stasis ulcers, varicose ulcers) are wounds occurring due to improper functioning of venous valves, usually of the legs.1 Damaged venous valves allows the backflow of blood and cause pressure in the veins. Hence an arterial pressure reduces significantly than venous and therefore, blood is not pumped as effectively into the area.2

Venous ulcers can be very painful and may limit mobility and quality of life. The longer the duration of the venous ulcer, the more is the damage to skin and greater the difficulty in healing. The annual prevalence of venous leg ulcer among the elderly is 1.69%. The overall incidence rate is 0.76% in men and1. 42% in women.3 Conservative management of venous ulcers includes use of

Management of Non Healing Varicose Ulcer Through Ayurvedic Intervention - A Case StudySaurabh, PuShPalatha b Kamble

Dr. Saurabh, M.S (Ayu.), Consultant in Shalya Tantra, Dr. Pushpalatha B. Kamble,Principal and Chief Physician, RK University Ayurvedic College and Hospital Rajkot, Gujarat.

Specially Contributed to "The Antiseptic" Vol. 114 No. 5 & P : 39 - 41

abstract

Venous ulcers (stasis ulcers, varicose ulcers) are the wounds occurring due to inappropriate functioning of venous valves, and its clinical manifestation because of chronic venous insufficiency usually of the legs. The overall incidence rate is 0.76% in men and 1.42% in women. When a venous valve gets damaged, it allows backflow of blood, which causes pressure in the veins that leads to venous hypertension and, in turn leads to venous ulcers. These are mostly along the medial distal leg, which is often very painful, can bleed, and get infected. Treating varicose ulcers is a difficult task to the physician and a nightmare to the suffering patients, though a good number of the treatment principles are mentioned and practiced in allied sciences. In Ayurveda, this condition is considered as dusta vrana. It can be managed with the specific shodhana therapy. So, the same treatment protocol was used to treat the case discussed here, i.e. with local application of tilastaka lepa and by Basti karma. The wound was successfully treated therefore, is discussed in detail.Key Words: Basti karma, Dustha vrana, tilastaka lepa, varicose ulcer

compression stocking or bandage to prevent worsening of varicose veins, foot elevation, antibiotics and regular cleaning and dressing of ulcer. However, if patient do not respond, then surgical measures like skin grafting, terminal interruption of reflux source technique (TIRS) by sclerotherapy, laser ablation of varicose veins or surgical correction of superficial venous reflux is performed.4

If varicose ulcer is not treated properly or left untreated then, wound infection causing increased pain, swelling, redness and pus, loss of mobility and even severe complications like osteomyelitis, septicaemia or malignancy etc. may occur. Statistics revealed that recurrence of venous ulcers is quite common, ranging from 54 to 78% by the fifth year after healing5.

Hence, we can say that in spite of all advances in health sciences, varicose ulcer management is still a difficult task for the surgeons.Pathology in delaying varicose ulcer healing: 6

The pathogenesis of varicose ulcer starts with dysfunction of venous valves causing venous hypertension which stretches the veins. This allows blood proteins to leak into the extra vascular space. It isolates extra cellular matrix molecule and growth factor, preventing them from helping to heal the wound. Similarly, leaking of fibrinogen and deficiency in fibrinolysis cause fibrin to build up around vessels preventing oxygen and nutrients from reaching cells. This also plugs the vessels causing ischemia around the wound resulting in delaying in wound healing. Further, the venous insufficiency causes leukocytes to accumulate in small vessels which releases inflammatory factors causes chronic wound formation.

Acharya Sushruta has described 60 measures for the comprehensive management of Vrana (wound), which includes local as well as the systematic use of different drugs and treatment modalities under a dedicated chapter. In the treatment of Vrana, Acharya

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SaindhavLavana 5gmManjishthadi Kalka 40gmMurchitaTilaTaila 60mlMadhu 80mlManjishthadiKwath 100mlGomutra 100mlKanji 100mlTotal 480ml

Sushruta mentioned the Dushta Vrana (chronic wounds), which is difficult to heal.7 Dushta is one in which there is localization of three dosha. Vrana, which had a bad odor, has abnormal color, with profuse discharge, intense pain and takes a long period to heal. Dushta Vrana is a long standing ulcer where shodhana (local and systemic purification)andropana (which promotes normal wound healing) are more important.case report

A male patient, aged 47 years, presented to OPD of Shalya Tantra with non‑healing ulcer with foul smelling discharge on the left leg above medial malleolar region associated with blackish discoloration of both feet, pain and swelling near left ankle joints since five years.H/o. Presenting complaints.:

Patients was apparently normal five years back. Gradually he developed discolouration over both lower limbs near ankle later it associated with itching and burning sensation specially during night. He noticed a small ulcer on left leg (medial side of lt. Anklejoint) for that he consulted doctor andtook medicationfor 2 years, got only symptomatically relief .Later symptoms reappeared.He was habituated to standing for long hours in his job, i.e. about 8 to 10, hours for the past 20 years. On examination; there was pain, swelling and dilated tortuous veins in the foreleg as well as in the calf region. There was swelling, and exfoliation of skin with serous discharges in the left ankle region with evident blackish blue discolouration. Patient was having regular daily activities expect sleep which was disturbed during night due to pain. He had addicted smoking generally 5‑8 cigarettes per day since last 20

years. Patient had no history of diabetic mellitus, hypertension, tuberculosis, venereal diseases, bronchial asthma, anaemia, cardiac diseases and any other major illness. He did not reported any surgical history in past. Routine blood investigations for complete blood count (CBC), blood sugar level and serum creatinine , lipid profile were normalFor all these complaints he got admitted at Rk Ayurveda hospital for further management.treatment

Ulcers cleaned with triphala kashyam8 and a freshly prepared tilastaka lepa applied daily on ulcers in a thickness of 0.5cm and kept till it starts drying, later lepa was removed followed by regular gauze dressing with Jatyadi taila.9 internally patient was given Tab. Kaishor Guggulu11

(450mg) one t.i.d, Tab. Gandhak Rasayana12 (250mg.) one t.i.d, Mahamanjistadi Kwatha13 40ml twice. As a shodhana (purification therapy) manjistadi kshar14,15 yoga basti

(table‑2) was planned. Tilastaka Lepa10–Tila, Nimba, Haridra, Daruharidra, Trivit, Saindhava, Gritam, Yastimadhu

Observations:

The characteristics of Dushta Vrana like Ativivrita (broad base), Bhairava (ugly look), Putipuyamansa (pus discharge), Durgandha (foul smell), Vedana (pain), Dirghakalanubandhi (chronic) were noted in the wound [Figure 1]. The ulcer was cleaned daily with triphalaquatha and then freshly prepared tilastaka lepa was applied in adequate quantity. ulcer was then bandaged after covering with sterilized gauze. It was observed that the slough at the floor of the wound and foul‑smelling bloody tinge discharges was significantly reduced 8th day of lepa application. [Figure 2]. The healing was started with the formation of healthy granulation tissue. The margin of ulcer became bluish showing growing epithelium. The tilastaka lepa dressing was continued till 15 days and later dressing with Jatyadi taila was continued till complete healing. On 60th day, it was observed that wound size was markedly reduced with normal skin coloration at the healed area [Figure 3]. On the 3rd month, the ulcer was healed completely with minimum scar tissue formation [Figure 4]. Follow up advices

Advice to review at every 15 days.

Avoidance of prolonged standing.

illustrations and tables table.1 manjistadi Kshar Yoga basti

Days 1 2 3 4 5 6 7 8Basti M MK M MK M MK M M

M – Matra Basti with Dhanwanter Taila 30ml MK – Manjishthadi Kshara Niruha Basti 480ml

table - 2 ingredients of manjistadi Kshar basti

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Raise limbs during sleep. Calf muscle strengthen exercise

(bicycle riding in the air while lying on back)

Dietary advice‑Avoid oily and spicy food, bakery items, curds, excessive sweets etc.

conclusion

This single case study highlighted the topical application of tilastaka lepa with basti treatment industa vrana (varicose ulcer). Tilastaka lepaalong with manjistadiksharbasti treatment and internal medication was found very effective and shown excellent healing effect in a case of chronic and nonhealing ulcers .Shodhana with local care can initiate significant healing along with reduction in pain, tenderness and swelling as we have demonstrated in this case.references -

1. Venous ulcer available from: http://www.en.wikipedia.org/wiki/Venous_ulcer [Last accessed on 2013 Mar 21].

2. Das S. A concise textbook of surgery.1st ed. Diseases of veins editionpublished by S. Das publication 13, old mayors’ court Calcutta.

3. Margolis, Bilker W, Santanna J, Baumgarten M. Venous l eg u l ce r : I nc i dence and prevalence in the elderly. J Am AcadDermatol2002;46:381‑6.

4. Bush, R. New technique to heal venous ulcers: Terminal interruption of the reflux source (TIRS). Perspectives in Vascular Surgery and Endovascular Therapy, 2010; 22

5. Brem H, Kirsner RS, Falanga V, Pro‑tocol for successful non‑ surgical treatment of venous ulcer, Am J. Surg. 2004; 188 (1A Suppl): 1‑8.

6. Beebe HG, Bergan JJ, Bergqvist D, Eklöf, B, Eriksson, I, Goldman MP,et al. Classification and grading of chronic venous disease in the lower limbs: a consensus statement. VascSurg 1996;30:5‑11.

7. Sushruta. SusruthaSamhitha, Sutra Sthana, KrutyakrutavidhiAdhyaya, 23/7, edited by Shastri A, 12th ed. ChaukhambhaSanskri taSansthan, Varanasi, 2001; 98.]

8. Sushruta, Sushruta Samhita with NimandhaSangraha commentary of Sri Dalhanacharya, edited by Vaidya YadavajiTrikamji Acharya, Chau‑khambaSurbharatiPrakashan Varanasi 2012, Chikitsasthana 1/17, p. 399.

9. Kaviraj Shri Govindadassen, B h a i s h a j y a R a t n a v a l i , Ambikadatha Shasthr i (edi ted), ChaukhambaSubharathiPrakashana, 2010, Chapt.47:pp1312, pg.no.824.

10. Chakradutta:P.V.Sharma Sanskrit text with English translation published by: Chaukhambhaorientaliadelhi forth edition2007 44:28pp739 pg358

11. GovindaDasa, BhaishajyaRatnavali, Varanasi, Chaukambha Sanskrit Samsthana, Uttar Pradesh, 2002, 47/51, PP 892, Page No. 38

12. Sri Sadanand Sharma, Rasa Tarangini, Delhi, Motilal Banarasidas,1994, chap. No.8/36‑38, 772pp, pg.no.181

13. Vagbhata, AshtangHrudaya,Delhi, Chaukambha Sanskrit Pratishthan, 2003, sutrasthana .15/19‑20, 956pp, pg.no236

14. Chakradatta, IndradevTripathi , Chaukhamba Sanskrit Sansthan, Varanasi, 2005, PP 542, Page Number 455.

15. Sharangdhar Samhita, Bramhanand Tripathi, Chaukhamba Surbharti Prakashan, Varanasi, 2007, PP 488, Page number 153).

Fig. 3 on 2nd month

Fig.1 On admission day

before treatment

Fig.2 after 15 days

application of tilastaka lepa

Fig. 4 on 3rd month